Fillable Pre-1957 Military Service Federal Benefit Questionnaire (Social Security Administration)

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Pre-1957 Military Service Federal Benefit Questionnaire (Social Security Administration)

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Form SSA-2512 (10-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0120
PRE-1957 MILITARY SERVICE - FEDERAL BENEFIT QUESTIONNAIRE
Name of Wage Earner (First Name, Middle Initial, Last Name)
Name Used in Service (if different from above)
Social Security Number
Service Number
PART 1 - MILITARY SERVICE HISTORY - PRIOR TO 1957
Enter the month, day, and year of any active or reserve military service during the period September 16, 1940 through
December 31, 1956. If the service BEGAN BEFORE OR ENDED AFTER this period, show the starting or ending date
even though it is outside the period.
1.
ACTIVE DUTY - REGULAR AND ACTIVE RESERVE SERVICE
Enter information about REGULAR ACTIVE DUTY of any duration and about RESERVE ACTIVE SERVICE of 90 consecutive
days or more while on active duty or active duty for training
(a) Branch of Service
(b) Date Active Duty
Began
Month Day Year
(c) Date Separated
From Active Duty
Month Day Year
(d) Rate or Rank
2.
RESERVE SERVICE (Other than Active Reserve Duty Shown Above.)
(a) Branch of Service
(b) Date Active Duty
Began
Month Day Year
(c) Date Separated
From Active Duty
Month Day Year
(d) Rate or Rank
PART 2 - MILITARY RETIREMENT INFORMATION
3.
(a)
Not retired (If checked, go on to Part 3)
(b)
Retired
• (If veteran is giving information complete (c) and (d) below.)
• (If survivor of veteran is giving information go on to Part 3)
(c) Basis for retirement (Complete even if not receiving pay)
Length of service Disability
Reserve service - Payable at age 60 Basis unknown
Other
(Please Specify)
(d) Did you waive all or part of your retirement pay as a condition to receive veterans' administration disability compensation or
to receive "civil service" (Office of Personnel Management) or other Federal agency credit for your military service?
Yes No
PART 3 - CIVILIAN FEDERAL AGENCY BENEFIT INFORMATION
(Including Veterans Administration)
4. (a) Have you ever been, or do you expect to be, entitled to receive a civilian Federal benefit?
Yes No (If "no", omit the remaining questions and sign below.)
(b) Please check type of benefit that you are receiving, were receiving, or that you expect to receive.
Age or Length of service Disability
Survivor Other
(Please Specify Type)
Form SSA-2512 (10-2019) Page 2 of 3
5. (a) Name of Federal agency that was, is now, or will be paying benefit:
Office of Personnel Management (Formerly Civil Service Commission)
Veterans' Administration (Check only if receiving benefits because of waiving all or part of military retirement pay)
Office of Workers Compensation Programs (Check only if receiving benefits because of waiving all or part of another
Federal benefit) Specify in remarks the agency and the type of benefit waived.
Other (Specify)
(b) Years of civilian Federal employment (c) Date claim filed (d) Federal Benefit claim number
6.
MOST RECENT Federal employer:
(a) Name of agency (if different from 5(a) above)
(b) City and State where employed
(c) Date last worked
REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.)
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or
imprisonment.
SIGNATURE OF APPLICANT
Signature (First Name, Middle Initial, Last Name) (Write in ink) Date (Month, day, year)
Telephone Number
(include area code)
Mailing Address (Number and Street, Apt. No., P.O. Box, or Rural Route)
City and State ZIP Code
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
2. Signature of Witness
Address (Number and street, City, State, and ZIP Code)
Form SSA-2512 (10-2019) Page 3 of 3
Privacy Act Statement
Collection and Use of Personal Information
Section 217 (a) through (e) of the Social Security Act and Section 20 of the Code of Federal Regulations 404.1301 through
404.1371, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide
all or part of the information could prevent us from making an accurate and timely decision on your claim, and could result in the
loss of benefits.
We will use the information to determine entitlement eligibility or the amount of Social Security benefits based on your military
service. We may also share your information for the following purposes, called routine uses:
• To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash income maintenance
or health maintenance programs (including programs under the Social Security Act). Such disclosures include, but are
not limited to, release of information to the Veterans Administration (VA) for administering 38 U.S.C. 412, and upon
request, information needed to determine eligibility for or amount of VA benefits or verifying other information with
respect thereto; and,
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under this routine use
only in situations in which SSA may enter a contractual or similar agreement with a third party to assist in
accomplishing an Agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN), 60-0089, Claims Folders
System, as published in the FR on April 1. 2003,at 68 FR 15784 and 60-0103, Supplemental Security Income Record and Special
Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all our
SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
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Pre-1957 Military Service Federal Benefit Questionnaire (Social Security Administration)

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Completed 23 July 2020

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